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Duncan DR, Golden C, Growdon AS, Larson K, Rosen RL. Brief Resolved Unexplained Events Symptoms Frequently Result in Inappropriate Gastrointestinal Diagnoses and Treatment. J Pediatr 2024:114128. [PMID: 38815745 DOI: 10.1016/j.jpeds.2024.114128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 04/19/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To determine associations between presenting symptoms and oropharyngeal dysphagia diagnoses, gastroesophageal reflux disease (GERD) diagnoses, and treatment with acid suppression medication in infants with brief resolved unexplained event (BRUE). STUDY DESIGN We performed a prospective cohort study of infants with BRUE to review presenting symptoms and their potential impact on testing and treatment. Videofluoroscopic swallow study (VFSS) results and explanatory diagnoses were obtained from medical record review; acid suppression use was determined by parental survey. Binary and multivariable logistic regression models were used to evaluate associations between presenting symptoms and obtaining VFSS, VFSS results, GERD diagnoses, and acid suppression medication. RESULTS Presenting symptoms were varied in 157 subjects enrolled at 51.0±5.3 days of age, with many symptoms that may be related to GERD or dysphagia. Of these, 28% underwent VFSS with 71% abnormal. Overall, 42% had their BRUE attributed to GERD and 33% were treated with acid suppression during follow-up. Presenting symptoms were significantly associated with the decision to obtain VFSS but not with abnormal VFSS results. Presenting symptoms were also associated with provision of GERD explanatory diagnoses. Both presenting symptoms and GERD explanatory diagnoses were associated with acid suppression use (aOR 2.3, 95% CI 1.03-5.3, p=0.04). CONCLUSIONS Presenting symptoms may play a role in clinicians' decisions about which BRUE patients undergo VFSS but are unreliable to make a diagnosis of oropharyngeal dysphagia. Presenting symptoms may also influence assignment of a GERD explanatory diagnoses that is associated with increased acid suppression medication use.
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Affiliation(s)
- Daniel R Duncan
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts;.
| | - Clare Golden
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Amanda S Growdon
- Hospital Medicine Program, Division of General Pediatrics, Boston Children's Hospital, Boston, MA
| | - Kara Larson
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Rachel L Rosen
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
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Nama N, DeLaroche AM, Neuman MI, Mittal MK, Herman BE, Hochreiter D, Kaplan RL, Stephans A, Tieder JS. Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments. Acad Emerg Med 2024. [PMID: 38426635 DOI: 10.1111/acem.14881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/10/2024] [Accepted: 01/20/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs). METHODS Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use. RESULTS Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82). CONCLUSIONS BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.
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Affiliation(s)
- Nassr Nama
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Manoj K Mittal
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bruce E Herman
- Division of Pediatric Emergency Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Daniela Hochreiter
- Department of Pediatrics, Division of Hospital Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ron L Kaplan
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Allayne Stephans
- Division of Pediatric Hospital Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Joel S Tieder
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
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Chen HH, Wang IA, Hsieh TW, Tsay JH, Chen CY. Early predictors for maltreatment-related injuries in infancy and long-term mortality: a population-based study. BMC Public Health 2023; 23:2232. [PMID: 37957616 PMCID: PMC10641954 DOI: 10.1186/s12889-023-17180-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 11/07/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION Incidence, health consequences, and social burden associated with child maltreatment appeared to be borne disproportionately by very young children. We conducted a population-based data linkage study to explore child- and family-level factors that affect receiving different diagnoses of maltreatment injuries and investigate excessive mortality throughout toddlerhood. METHODS We conducted a retrospective cohort study comprising 2.2 million infants born in 2004-2014 in Taiwan. Incident cases of child maltreatment were defined by hospitalization or emergency department visits for three heterogeneous diagnostic groups of maltreatment-related injuries (i.e., maltreatment syndrome, assaults, and undetermined causes) within 12 months after birth. The generalized linear model and landmark survival analyses were used to evaluate risk factors. RESULTS An estimated 2.9‰ of infants experienced at least one maltreatment-related injury, with a three-year mortality rate of 1.3%. Low birthweight was associated with increased risk of receiving the diagnosis of three maltreatment injuries, particularly maltreatment syndrome (adjusted Incidence Rate Ratio [aIRR] = 4.08, 95% confidence interval [CI]: 2.93-5.68). Socially advantaged family condition was inversely linked with receiving the diagnosis of maltreatment syndrome and assaults (e.g., high income: aIRR = 0.55 and 0.47), yet positively linked with undetermined cause (aIRR = 2.05, 95% CI: 1.89-2.23). For infants exposed to maltreatment, low birth weight and non-attendance of postnatal care were highly predictive of fatality; low birthweight served as a vital predictor for premature death during toddlerhood (aIRR = 6.17, 95% CI: 2.36-15.4). CONCLUSIONS Raising awareness of maltreatment-related injuries in infancy and predictors should be a priority for appropriate follow-up assessment and timely intervention.
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Affiliation(s)
- Hsin-Hung Chen
- Institute of Public Health, National Yang Ming Chiao Tung University, Medical Building II, No. 155, Sec. 2, Linong Street, Taipei, 112, Taiwan
- Division of Pediatric Neurosurgery, The Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - I-An Wang
- Center of Neuropsychiatric Research, National Health Research Institutes, Zhunan, Taiwan
| | - Tan-Wen Hsieh
- Center of Neuropsychiatric Research, National Health Research Institutes, Zhunan, Taiwan
| | - Jen-Huoy Tsay
- Department of Social Work, National Taiwan University, Taipei, Taiwan
| | - Chuan-Yu Chen
- Institute of Public Health, National Yang Ming Chiao Tung University, Medical Building II, No. 155, Sec. 2, Linong Street, Taipei, 112, Taiwan.
- Center of Neuropsychiatric Research, National Health Research Institutes, Zhunan, Taiwan.
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4
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Egge MK. Medical Child Abuse: A Review by Subspecialty. Adv Pediatr 2023; 70:59-80. [PMID: 37422298 DOI: 10.1016/j.yapd.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
Medical child abuse (MCA), formerly called Munchausen syndrome by proxy (MSP or MSBP), occurs when a caregiver, usually the mother, falsifies or exaggerates symptoms resulting in harm to a child through inappropriate medical care. MCA is underrecognized, underreported, and results in significant morbidity and mortality. Pediatrics subspecialists should consider MCA when unusual disease presentation [THAT] do not respond to traditional treatments. This article reviews the more common diagnoses encountered in MCA cases by specialty.
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Affiliation(s)
- Melissa K Egge
- Pediatrics, Stanford Medicine Children's Health - Lucile Packard, 700 Welch Road, Suite 300G, MC 6583, Palo Alto, CA 94304, USA.
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5
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Denis M, Brulé C, Lauzier B, Brossier D, Porcheret F. Brief resolved unexplained event: Severity-associated factors at admission in the pediatric emergency ward. Arch Pediatr 2023:S0929-693X(23)00087-8. [PMID: 37330397 DOI: 10.1016/j.arcped.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 10/26/2022] [Accepted: 05/21/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE A brief resolved unexplained event (BRUE) is a recent clinical entity that has now replaced the term "infant discomfort". Despite the availability of recent recommendations, identification of patients requiring further examination remains difficult. METHOD We aimed to identify factors associated with severe pathology and/or recurrence by studying the medical files of 767 patients admitted to the pediatric emergency department of a French university hospital for a BRUE. RESULTS Overall, 255 files were studied; 45 patients had a recurrence and 23 patients had a severe diagnosis. The most frequently found etiology was gastroesophageal reflux in the benign diagnosis group and apnea or central hypoventilation in the severe diagnosis group. Prematurity (p = 0.032) and time since last meal >1 h (p = 0.019) were the main factors associated with severe disease. Most of the routine examination results remained non-contributive to the etiology. CONCLUSION As prematurity is a factor associated with severe diagnosis, special attention should be given to this population, without subjecting them to multiple tests, since the main complication was found to be apnea or central hypoventilation. Prospective research is needed to establish the usefulness and prioritization of diagnostic tests for infants who are at "high risk" of experiencing a BRUE.
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Affiliation(s)
- Manon Denis
- Pediatric Intensive Care Unit, CHU de Caen, Caen, F-14000, France; Pediatric Intensive Care Unit, CHU de Nantes, Nantes, F-44000, France; Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000, France.
| | - C Brulé
- Department of Pediatrics, CHU de Caen, Caen, F-14000, France
| | - B Lauzier
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000, France
| | - D Brossier
- Pediatric Intensive Care Unit, CHU de Caen, Caen, F-14000, France; Université Caen Normandie, medical school, Caen, F-14000, France; Université Caen Normandie, GREYC, Caen, F-14000, France
| | - F Porcheret
- Pediatric Intensive Care Unit, CHU de Caen, Caen, F-14000, France; Service de Maladies chroniques pédiatriques, CHU de Nantes, Nantes, F-44000, France
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Shah AS, Leu RM, Shah SP, Martinez F, Kasi AS. Images: Caffeine therapy for central sleep apnea, hypoxemia, and hypoventilation in a term neonate. J Clin Sleep Med 2023; 19:1005-1008. [PMID: 36747487 PMCID: PMC10152353 DOI: 10.5664/jcsm.10504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023]
Abstract
The evaluation of higher-risk infants with brief resolved unexplained events and term infants with central sleep apnea can be clinically challenging due to the multitude of potential etiologies. We report a 7-day-old term neonate hospitalized for evaluation of brief resolved unexplained events with oxygen desaturations during sleep. Polysomnography showed central sleep apnea, hypoxemia, hypoventilation, periodic breathing, and mild obstructive sleep apnea. Following initial evaluations and while awaiting genetic testing, primary central sleep apnea of infancy was suspected and caffeine was initiated. Three days after initiating caffeine, polysomnography showed resolution of hypoxemia, hypoventilation, obstructive sleep apnea, and periodic breathing and improved central sleep apnea. The central apnea-hypopnea index reduced from 58 to 6.8 events/h. Although caffeine is utilized in apnea of prematurity, there is limited literature regarding caffeine in term infants with apnea. Our case demonstrates that in term infants with primary central sleep apnea of infancy, immature regulation of respiration may persist and a trial of caffeine could be considered. CITATION Shah AS, Leu RM, Shah SP, Martinez F, Kasi AS. Caffeine therapy for central sleep apnea, hypoxemia, and hypoventilation in a term neonate. J Clin Sleep Med. 2023;19(5):1005-1008.
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Affiliation(s)
- Amit S. Shah
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Roberta M. Leu
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Samar P. Shah
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Frances Martinez
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Ajay S. Kasi
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
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Doswell A, Anderst J, Tieder JS, Herman BE, Hall M, Wilkins V, Knochel ML, Kaplan R, Cohen A, DeLaroche AM, Harper B, Mittal MK, Shastri N, Prusakowski M, Puls HT. Diagnostic testing for and detection of physical abuse in infants with brief resolved unexplained events. CHILD ABUSE & NEGLECT 2023; 135:105952. [PMID: 36423537 DOI: 10.1016/j.chiabu.2022.105952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND A Brief Resolved Unexplained Event (BRUE) can be a sign of occult physical abuse. OBJECTIVES To identify rates of diagnostic testing able to detect physical abuse (head imaging, skeletal survey, and liver transaminases) at BRUE presentation. The secondary objective was to estimate the rate of physical abuse diagnosed at initial BRUE presentation through 1 year of age. PARTICIPANTS AND SETTING Infants who presented with a BRUE at one of 15 academic or community hospitals were followed from initial BRUE presentation until 1 year of age for BRUE recurrence or revisits. METHODS This study was part of the BRUE Research and Quality Improvement Network, a multicenter retrospective cohort examining infants with BRUE. Generalized estimating equations assessed associations with performance of diagnostic testing (adjusted odds ratio (aOR)). RESULTS Of the 2036 infants presenting with a BRUE, 6.2 % underwent head imaging, 7.0 % skeletal survey, and 12.1 % liver transaminases. Infants were more likely to undergo skeletal survey if there were physical examination findings concerning for trauma (aOR 8.23, 95 % CI [1.92, 35.24], p < 0.005) or concerning social history (aOR 1.89, 95 % CI [1.13, 3.16], p = 0.015). There were 7 (0.3 %) infants diagnosed with physical abuse: one at BRUE presentation, one <3 days after BRUE presentation, and five >30 days after BRUE presentation. CONCLUSION There were low rates of diagnostic testing and physical abuse identified in infants presenting with BRUE. Further study including standardized testing protocols is warranted to identify physical abuse in infants presenting with a BRUE.
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Affiliation(s)
- Angela Doswell
- Division of Child Abuse and Neglect, Department of Pediatrics, Connecticut Children's Medical Center and University of Connecticut School of Medicine, 282 Washington Street, Hartford, CT 06106, United States of America.
| | - James Anderst
- Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri and University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
| | - Joel S Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and School of Medicine, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105, United States of America
| | - Bruce E Herman
- Division of Pediatric Emergency Medicine, Primary Children's Hospital and University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States of America
| | - Matt Hall
- Children's Hospital Association, 16011 College Boulevard, Lenexa, KS 66219, United States of America
| | - Victoria Wilkins
- Division of Pediatric Hospital Medicine, Primary Children's Hospital and University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States of America
| | - Miguel L Knochel
- Division of Pediatric Hospital Medicine, Primary Children's Hospital and University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States of America
| | - Ron Kaplan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, United States of America
| | - Adam Cohen
- Division of Hospital Medicine, Department of Pediatrics and Department of Education, Innovation and Technology, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, United States of America
| | - Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48201, United States of America
| | - Beth Harper
- Division of Hospital Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America
| | - Manoj K Mittal
- Division of Emergency Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States of America
| | - Nirav Shastri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri and University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
| | - Melanie Prusakowski
- Department of Emergency Medicine, Carilion Children's Hospital, 1906 Belleview Avenue SE, Roanoke, VA 24014, United States of America
| | - Henry T Puls
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri and University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
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8
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Duncan DR, Liu E, Growdon AS, Larson K, Rosen RL. A Prospective Study of Brief Resolved Unexplained Events: Risk Factors for Persistent Symptoms. Hosp Pediatr 2022; 12:1030-1043. [PMID: 36336644 PMCID: PMC9724174 DOI: 10.1542/hpeds.2022-006550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The risk of persistent symptoms after a brief resolved unexplained event (BRUE) is not known. Our objective was to determine the frequency and risk factors for persistent symptoms after BRUE hospitalizations. METHODS We conducted a prospective longitudinal cohort study of infants hospitalized with an admitting diagnosis of BRUE. Caregiver-reported symptoms, anxiety levels, and management changes were obtained by questionnaires during the 2-month follow-up period. Clinical data including repeat hospitalizations were obtained from a medical record review. Multivariable analyses with generalized estimating equations were conducted to determine the risk of persistent symptoms. RESULTS Of 124 subjects enrolled at 51.6 ± 5.9 days of age, 86% reported symptoms on at least 1 questionnaire after discharge; 65% of patients had choking episodes, 12% had BRUE spells, and 15% required a repeat hospital visit. High anxiety levels were reported by 31% of caregivers. Management changes were common during the follow-up period and included 30% receiving acid suppression and 27% receiving thickened feedings. Only 19% of patients had a videofluoroscopic swallow study while admitted, yet 67% of these studies revealed aspiration/penetration. CONCLUSIONS Many infants admitted with BRUE have persistent symptoms and continue to access medical care, suggesting current management strategies insufficiently address persistent symptoms. Future randomized trials will be needed to evaluate the potential efficacy of therapies commonly recommended after BRUE.
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Affiliation(s)
- Daniel R. Duncan
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research
| | - Amanda S. Growdon
- Hospital Medicine Program, Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Kara Larson
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition
| | - Rachel L. Rosen
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition
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Nama N, Hosseini P, Lee Z, Picco K, Bone JN, Foulds JL, Gagnon JA, Sehgal A, Quet J, Drouin O, Luu TM, Vomiero G, Kanani R, Holland J, Goldman RD, Kang KT, Mahant S, Jin F, Tieder JS, Gill PJ. Canadian infants presenting with Brief Resolved Unexplained Events (BRUEs) and validation of clinical prediction rules for risk stratification: a protocol for a multicentre, retrospective cohort study. BMJ Open 2022; 12:e063183. [PMID: 36283756 PMCID: PMC9608523 DOI: 10.1136/bmjopen-2022-063183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Brief Resolved Unexplained Events (BRUEs) are a common presentation among infants. While most of these events are benign and self-limited, guidelines published by the American Academy of Pediatrics inaccurately identify many patients as higher-risk of a serious underlying aetiology (positive predictive value 5%). Recently, new clinical prediction rules have been derived to more accurately stratify patients. This data were however geographically limited to the USA, with no large studies to date assessing the BRUE population in a different healthcare setting. The study's aim is to describe the clinical management and outcomes of infants presenting to Canadian hospitals with BRUEs and to externally validate the BRUE clinical prediction rules in identified cases. METHODS AND ANALYSIS This is a multicentre retrospective study, conducted within the Canadian Paediatric Inpatient Research Network (PIRN). Infants (<1 year) presenting with a BRUE at one of 11 Canadian paediatric centres between 1 January 2017 and 31 December 2021 will be included. Eligible patients will be identified using diagnostic codes.The primary outcome will be the presence of a serious underlying illness. Secondary outcomes will include BRUE recurrence and length of hospital stay. We will describe the rates of hospital admissions and whether hospitalisation was associated with an earlier diagnosis or treatment. Variation across Canadian hospitals will be assessed using intraclass correlation coefficient. To validate the newly developed clinical prediction rule, measures of goodness of fit will be evaluated. For this validation, a sample size of 1182 is required to provide a power of 80% to detect patients with a serious underlying illness with a significance level of 5%. ETHICS AND DISSEMINATION Ethics approval has been granted by the UBC Children's and Women's Research Board (H21-02357). The results of this study will be disseminated as peer-reviewed manuscripts and presentations at national and international conferences.
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Affiliation(s)
- Nassr Nama
- Division of General Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
- Department of Pediatrics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Parnian Hosseini
- Department of Pediatrics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Zerlyn Lee
- Department of Pediatrics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Kara Picco
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeffrey N Bone
- Research Informatics, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Jessica L Foulds
- Department of Pediatrics, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Josée Anne Gagnon
- Department of Pediatrics, CHU de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - Anupam Sehgal
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Olivier Drouin
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Thuy Mai Luu
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Gemma Vomiero
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Ronik Kanani
- Department of Pediatrics, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joanna Holland
- Department of Pediatrics, Division of General Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Ran D Goldman
- The Pediatric Research in Emergency Therapeutics (PRETx) Program, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Emergency Medicine, Department of Pediatrics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Kristopher T Kang
- Division of General Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
- Department of Pediatrics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Sanjay Mahant
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Falla Jin
- Clinical Research Support Unit, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Joel S Tieder
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Peter J Gill
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
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Nama N, Hall M, Neuman M, Sullivan E, Bochner R, De Laroche A, Hadvani T, Jain S, Katsogridakis Y, Kim E, Mittal M, Payson A, Prusakowski M, Shastri N, Stephans A, Westphal K, Wilkins V, Tieder J. Risk Prediction After a Brief Resolved Unexplained Event. Hosp Pediatr 2022; 12:772-785. [PMID: 35965279 DOI: 10.1542/hpeds.2022-006637] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Only 4% of brief resolved unexplained events (BRUE) are caused by a serious underlying illness. The American Academy of Pediatrics (AAP) guidelines do not distinguish patients who would benefit from further investigation and hospitalization. We aimed to derive and validate a clinical decision rule for predicting the risk of a serious underlying diagnosis or event recurrence. METHODS We retrospectively identified infants presenting with a BRUE to 15 children's hospitals (2015-2020). We used logistic regression in a split-sample to derive and validate a risk prediction model. RESULTS Of 3283 eligible patients, 565 (17.2%) had a serious underlying diagnosis (n = 150) or a recurrent event (n = 469). The AAP's higher-risk criteria were met in 91.5% (n = 3005) and predicted a serious diagnosis with 95.3% sensitivity, 8.6% specificity, and an area under the curve of 0.52 (95% confidence interval [CI]: 0.47-0.57). A derived model based on age, previous events, and abnormal medical history demonstrated an area under the curve of 0.64 (95%CI: 0.59-0.70). In contrast to the AAP criteria, patients >60 days were more likely to have a serious underlying diagnosis (odds ratio:1.43, 95%CI: 1.03-1.98, P = .03). CONCLUSIONS Most infants presenting with a BRUE do not have a serious underlying pathology requiring prompt diagnosis. We derived 2 models to predict the risk of a serious diagnosis and event recurrence. A decision support tool based on this model may aid clinicians and caregivers in the discussion on the benefit of diagnostic testing and hospitalization (https://www.mdcalc.com/calc/10400/brief-resolved-unexplained-events-2.0-brue-2.0-criteria-infants).
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Affiliation(s)
- Nassr Nama
- Division of General Pediatrics, Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Mark Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Erin Sullivan
- Department of Pediatrics, University of Washington, Seattle Children's Core for Biomedical Statistics, Seattle, Washington
| | - Risa Bochner
- SUNY Downstate Health Sciences University/New York City Health and Hospitals/Kings County Hospital, New York City, New York
| | - Amy De Laroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Teena Hadvani
- Division of Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Shobhit Jain
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Kansas
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Edward Kim
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Manoj Mittal
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Nirav Shastri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Kansas
| | | | - Kathryn Westphal
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Victoria Wilkins
- Division of Pediatric Hospital Medicine, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Joel Tieder
- Division of Pediatric Hospital Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
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11
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Silksmith B, Munot P, Starling L, Pujar S, Matthews E. Accelerating the genetic diagnosis of neurological disorders presenting with episodic apnoea in infancy. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:495-508. [PMID: 35525254 DOI: 10.1016/s2352-4642(22)00091-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/25/2022] [Accepted: 03/03/2022] [Indexed: 11/26/2022]
Abstract
Unexplained episodic apnoea in infants (aged ≤1 year), including recurrent brief (<1 min) resolved unexplained events (known as BRUE), can be a diagnostic challenge. Recurrent unexplained apnoea might suggest a persistent, debilitating, and potentially fatal disorder. Genetic diseases are prevalent among this group, particularly in those who present with paroxysmal or episodic neurological symptoms. These disorders are individually rare and challenging for a general paediatrician to recognise, and there is often a delayed or even posthumous diagnosis (sometimes only made in retrospect when a second sibling becomes unwell). The disorders can be debilitating if untreated but pharmacotherapies are available for the vast majority. That any child should suffer from unnecessary morbidity or die from one of these disorders without a diagnosis or treatment having been offered is a tragedy; therefore, there is an urgent need to simplify and expedite the diagnostic journey. We propose an apnoea gene panel for hospital specialists caring for any infant who has recurrent apnoea without an obvious cause. This approach could remove the need to identify individual rare conditions, speed up diagnosis, and improve access to therapy, with the ultimate aim of reducing morbidity and mortality.
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Affiliation(s)
- Bryony Silksmith
- Department of Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Pinki Munot
- Dubowitz Neuromuscular Centre, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Luke Starling
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Suresh Pujar
- Department of Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Emma Matthews
- Atkinson-Morley Neuromuscular Centre, Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK; Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.
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12
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Easter J, Petruzella F. Updates in pediatric emergency medicine for 2021. Am J Emerg Med 2022; 56:244-253. [DOI: 10.1016/j.ajem.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/03/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022] Open
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13
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Ramgopal S, Colgan JY, Roland D, Pitetti RD, Katsogridakis Y. Brief resolved unexplained events: a new diagnosis, with implications for evaluation and management. Eur J Pediatr 2022; 181:463-470. [PMID: 34455524 DOI: 10.1007/s00431-021-04234-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
Abstract
Brief resolved unexplained events (BRUE) are concerning episodes of short duration (typically < 1 min) characterized by a change in breathing, consciousness, muscle tone (hyper- or hypotonia), and/or skin color (cyanosis or pallor). The episodes occur in a normal-appearing infant in the first year of life, self-resolve, and have no readily identifiable explanation for the cause of the event. Previously called apparent life-threatening events (ALTE), the term BRUE was first defined by the American Academy of Pediatrics (AAP) in 2016. The criteria for BRUE carry greater specificity compared to that of ALTE and additionally are indicative of a diagnosis of exclusion. While most patients with BRUE will have a benign clinical course, important etiologies, including airway, cardiac, gastrointestinal, genetic, infectious, neurologic, and traumatic conditions (including nonaccidental), must be carefully considered. A BRUE is classified as either lower- or higher-risk based on patient age, corrected gestational age, event duration, number of events, and performance of cardiopulmonary resuscitation at the scene. The AAP clinical practice guideline provides recommendations for the management of lower-risk BRUEs, advocating against routine admission, blood testing, and imaging for infants with these events, though a short period of observation and/or an electrocardiogram may be advisable. While guidance exists for higher-risk BRUE, more data are required to better identify proportions and risk factors for serious outcomes among these patients. Conclusion: BRUE is a diagnosis with greater specificity relative to prior definitions and is now a diagnosis of exclusion. Additional research is needed, particularly in the evaluation of higher-risk events. Recent data suggest that the AAP guidelines for the management of lower-risk infants can be safely implemented.This review article summarizes the history, definitional changes, current guideline recommendations, and future research needs for BRUE. What is Known: • BRUE, first described in 2016, is a diagnosis used to describe a well-appearing infant who presents with change in breathing, consciousness, muscle tone (hyper- or hypotonia), and/or skin color (cyanosis or pallor). • BRUE can be divided into higher- and lower-risk events. Guidelines have been published for lower-risk events, with expert recommendations for higher-risk BRUE. What is New: • BRUE carries a low rate of serious diagnoses (< 5%), with the most common representing seizures and airway abnormalities. • Prior BRUE events are associated with serious diagnoses and episode recurrence.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Jennifer Y Colgan
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK.,SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
| | - Raymond D Pitetti
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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14
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Rosen CL. Sleep-Disordered Breathing (SDB) in Pediatric Populations. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Gerber NL, Fawcett KJ, Weber EG, Patel R, Glick AF, Farkas JS, Mojica MA. Brief Resolved Unexplained Event: Not Just a New Name for Apparent Life-Threatening Event. Pediatr Emerg Care 2021; 37:e1439-e1443. [PMID: 32472924 DOI: 10.1097/pec.0000000000002069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This study aimed to evaluate patients who presented to the pediatric emergency department with an apparent life-threatening event (ALTE) to (1) determine if these patients would meet the criteria for brief resolved unexplained event (BRUE), a new term coined by the American Academy of Pediatrics in May, 2016; (2) risk stratify these patients to determine if they meet the BRUE low-risk criteria; and (3) evaluate outcomes of patients meeting the criteria for BRUE. METHODS We conducted a retrospective chart review of patients who presented to a large urban academic center pediatric emergency department with an ALTE from January 2013 to May 2015 (before the publication of the BRUE guideline). Children ≤12 months of age were identified by the International Classification of Diseases, Ninth/Tenth Revision. Two physician reviews were performed to determine if patients met the ALTE diagnostic criteria. Data were then extracted from these charts to complete objectives. RESULTS Seventy-eight patients met the diagnostic criteria for ALTE. Only 1 of those patients met the diagnostic criteria for BRUE, but not for low-risk BRUE. This patient underwent an extensive inpatient evaluation and was eventually discharged after monitoring with a benign diagnosis. Most patients did not meet the criteria for BRUE because the event was not unexplained. CONCLUSIONS Only 1 patient who presented to the ED with ALTE met the criteria for BRUE, and this patient did not meet the low-risk criteria. This study corroborates previous research on BRUE and continues to highlight the importance of conducting a thorough history and physical examination on all patients presenting to the ED with concerning events.
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Affiliation(s)
- Nicole L Gerber
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York Presbyterian-Weill Cornell Medical Center
| | - Kelsey J Fawcett
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York Presbyterian-Columbia University Medical Center, New York
| | - Emily G Weber
- Department of Emergency Medicine, SUNY Downstate Medical Center-Kings County Hospital Center, Brooklyn
| | | | | | | | - Michael A Mojica
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine/NYU Langone Health/Bellevue Hospital Center, New York, NY
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16
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Bochner R, Tieder JS, Sullivan E, Hall M, Stephans A, Mittal MK, Singh N, Delaney A, Harper B, Shastri N, Hochreiter D, Neuman MI. Explanatory Diagnoses Following Hospitalization for a Brief Resolved Unexplained Event. Pediatrics 2021; 148:peds.2021-052673. [PMID: 34607936 DOI: 10.1542/peds.2021-052673] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Most young infants presenting to the emergency department (ED) with a brief resolved unexplained event (BRUE) are hospitalized. We sought to determine the rate of explanatory diagnosis after hospitalization for a BRUE. METHODS This was a multicenter retrospective cohort study of infants hospitalized with a BRUE after an ED visit between October 1, 2015, and September 30, 2018. We included infants without an explanatory diagnosis at admission. We determined the proportion of patients with an explanatory diagnosis at the time of hospital discharge and whether diagnostic testing, consultation, or observed events occurring during hospitalization were associated with identification of an explanatory diagnosis. RESULTS Among 980 infants hospitalized after an ED visit for a BRUE without an explanatory diagnosis at admission, 363 (37.0%) had an explanatory diagnosis identified during hospitalization. In 805 (82.1%) infants, diagnostic testing, specialty consultations, and observed events did not contribute to an explanatory diagnosis, and, in 175 (17.9%) infants, they contributed to the explanatory diagnosis (7.0%, 10.0%, and 7.0%, respectively). A total of 15 infants had a serious diagnosis (4.1% of explanatory diagnoses; 1.5% of all infants hospitalized with a BRUE), the most common being seizure and infantile spasms, occurring in 4 patients. CONCLUSIONS Most infants hospitalized with a BRUE did not receive an explanation during the hospitalization, and a majority of diagnoses were benign or self-limited conditions. More research is needed to identify which infants with a BRUE are most likely to benefit from hospitalization for determining the etiology of the event.
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Affiliation(s)
- Risa Bochner
- State University of New York Downstate Health Sciences University and Department of Pediatrics, New York City Health and Hospitals Kings County, Brooklyn, New York
| | - Joel S Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's and School of Medicine, University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Allayne Stephans
- Division of Pediatric Hospital Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Manoj K Mittal
- Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nidhi Singh
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Atima Delaney
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Beth Harper
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Nirav Shastri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Kansas
| | - Daniela Hochreiter
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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17
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Maksimowski K, Haddad R, DeLaroche AM. Pediatrician Perspectives on Brief Resolved Unexplained Events. Hosp Pediatr 2021; 11:996-1003. [PMID: 34429345 DOI: 10.1542/hpeds.2021-005805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE The objective with this study was to describe pediatric emergency department (ED) physicians' perspective on the evaluation and management of brief resolved unexplained events (BRUEs) to help support the development of quality improvement interventions for this population. METHODS We conducted qualitative semistructured interviews with pediatric ED providers who practice in a single state. Interviews were audio-recorded and transcribed and demographic information was also obtained. The 6-phase approach to reflexive thematic analysis was used to conduct the qualitative analysis. RESULTS Nineteen pediatric ED physicians practicing in 4 institutions across our state participated in the study. The majority of participants (95%) practice in a university-affiliated setting. The primary themes related to providing care for patients with a BRUE identified in our analysis were (1) reassurance, (2) caregiver or provider concern, and (3) clinical practice guideline availability and interpretation. Closely intertwined underlying topics informing BRUE patient management were also noted: (1) ambiguity in the BRUE diagnosis and its management; (2) a need for shared decision-making between the caregiver and the provider; and (3) concern over the increased time spent with caregivers during an ED visit for a diagnosis of BRUE. These complex relationships were found to influence patient evaluation and disposition. CONCLUSION Multifaceted quality improvement interventions should address caregiver and provider concerns regarding the diagnosis of BRUE while providing decision aids to support shared decision-making with caregivers.
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Affiliation(s)
- Karolina Maksimowski
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Rita Haddad
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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18
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DeLaroche AM, Hall M, Mittal MK, Neuman MI, Stephans A, Wilkins VL, Sullivan E, Cohen A, Kaplan RL, Shastri NL, Tieder JS. Accuracy of Diagnostic Codes for Identifying Brief Resolved Unexplained Events. Hosp Pediatr 2021; 11:726-749. [PMID: 34183363 DOI: 10.1542/hpeds.2020-005330] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate International Classification of Diseases, 10th Revision (ICD-10) coding strategies for the identification of patients with a brief resolved unexplained event (BRUE). METHODS Multicenter retrospective cohort study, including patients aged <1 year with an emergency department (ED) visit between October 1, 2015, and September 30, 2018, and an ICD-10 code for the following: (1) BRUE; (2) characteristics of BRUE; (3) serious underlying diagnoses presenting as a BRUE; and (4) nonserious diagnoses presenting as a BRUE. Sixteen algorithms were developed by using various combinations of these 4 groups of ICD-10 codes. Manual chart review was used to assess the performance of these ICD-10 algorithms for the identification of (1) patients presenting to an ED who met the American Academy of Pediatrics clinical definition for a BRUE and (2) the subset of these patients discharged from the ED or hospital without an explanation for the BRUE. RESULTS Of 4512 records reviewed, 1646 (36.5%) of these patients met the American Academy of Pediatrics criteria for BRUE on ED presentation, 1016 (61.7%) were hospitalized, and 959 (58.3%) had no explanation on discharge. Among ED discharges, the BRUE ICD-10 code alone was optimal for case ascertainment (sensitivity: 89.8% to 92.8%; positive predictive value: 51.7% to 72.0%). For hospitalized patients, ICD-10 codes related to the clinical characteristics of BRUE are preferred (specificity 93.2%, positive predictive value 32.7% to 46.3%). CONCLUSIONS The BRUE ICD-10 code and/or the diagnostic codes for the characteristics of BRUE are recommended, but the choice between approaches depends on the investigative purpose and the specific BRUE population and setting of interest.
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Affiliation(s)
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Manoj K Mittal
- Children's Hospital of Pennsylvania and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Allayne Stephans
- University Hospitals, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Victoria L Wilkins
- Primary Children's Hospital and University of Utah, Salt Lake City, Utah
| | | | - Adam Cohen
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Ron L Kaplan
- Seattle Children's Hospital, Seattle, Washington.,Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, Washington
| | - Nirav L Shastri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Joel S Tieder
- Seattle Children's Hospital, Seattle, Washington.,Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, Washington
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19
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Minowa H. Neonatal respiratory inhibition. J Matern Fetal Neonatal Med 2021; 35:7132-7138. [PMID: 34182876 DOI: 10.1080/14767058.2021.1944094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To present information on neonatal respiratory inhibition (NRI) to the medical staff caring for infants. METHODS The author reviewed investigations of the above conditions. NRI is defined as severe hypoxemia accompanied by clinical manifestations of central cyanosis and a decrease in SpO2 to less than 70%. Neonatal respiratory inhibition consists of respiratory inhibition after crying (RIAC), feeding hypoxemia, and respiratory inhibition after gastroesophageal reflux (RIGER). The infants were monitored continuously via pulse oximetry from birth until discharge. To identify the details of NRI, we analyzed detailed notes taken by both parents and medical staff during monitoring using specific software designed to interpret pulse oximetry measurements. RESULTS Among infants who weighed at least 2000 g and who were born at a gestational age of at least 36 weeks, NRI was observed in ∼50% of infants, including RIAC in ∼25%, feeding hypoxemia in 40%, and RIGER in 2 ∼ 4%, respectively. Among the infants with NRI, ∼40% experienced one or more episodes of prolonged cyanosis for at least 60 s. RIAC, feeding hypoxemia, and RIGER is significantly associated with each other. Among perinatal factors, NRI was related to maternal diabetes mellitus, twin pregnancy, asymmetric intrauterine growth restriction, threatened premature labor, cesarean section, shorter gestational periods, and abnormal ultrasound findings, including increased echogenicity in the ganglionic eminence (GE), a cyst in the GE, a subependymal cyst, and slight lateral ventricular enlargement. Almost all infants with RIAC and RIGER, even those with severe cases, recovered until discharge around day 5. Despite the provision of nursing guidance in feeding control, ∼60% of infants experienced feeding hypoxemia continuously. The more frequently the infants experienced feeding hypoxemia, the more severe the degree of feeding hypoxemia became. Breastfeeding reduced the frequency and degree of feeding hypoxemia compared to bottle feeding. Approximately 40% of infants with feeding hypoxemia required additional feeding control after being discharged. CONCLUSIONS NRI is very common and occurs in many infants worldwide. The infants with NRI experienced repeated severe hypoxemia due to RIAC, feeding hypoxemia, and RIGER after birth. Breastfeeding and careful feeding control should be recommended to mothers of infants with repeated feeding hypoxemia. Spreading knowledge about NRI worldwide is very important.
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Affiliation(s)
- Hideki Minowa
- Department of Neonatal Intensive Care Unit, Nara Prefecture General Medical Center, Nara, Japan
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20
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Nosetti L, Agosti M, Franchini M, Milan V, Piacentini G, Zaffanello M. Long-Term Pulmonary Damage From SARS-CoV-2 in an Infant With Brief Unexplained Resolved Events: A Case Report. Front Med (Lausanne) 2021; 8:646837. [PMID: 34179037 PMCID: PMC8225923 DOI: 10.3389/fmed.2021.646837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 05/20/2021] [Indexed: 11/17/2022] Open
Abstract
A brief unexplained resolved event (BRUE) is an event observed in a child under 1 year of age in which the observer witnesses a sudden, brief but resolved episode of change in skin color, lack of breathing, weakness or poor responsiveness. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease-2019 (COVID-19). We report the case of a previously healthy, full-term infant infected with SARS-CoV-2 when he was 8 months old. Previous to this event, both his grandfather and great-uncle had died of severe pneumonia and his mother had developed respiratory symptoms and fever. Over the following month he was seen five times in the emergency room and was hospitalized twice for recurrent BRUE. At the first hospital admission, after the second emergency room visit, he twice tested positive for COVID-19 after nasopharyngeal swab tests. During his second hospital admission, after the fifth emergency room visit, chest computed tomography revealed typical SARS-CoV-2 pneumonia. During a follow-up examination 6 months later, mild respiratory distress required administration of inhaled oxygen (0.5 L/min) and chest computed tomography disclosed a slight improvement in pulmonary involvement. The clinical manifestation of pulmonary complications from COVID-19 infection was unusual. This is the first report of an infant at high-risk for BRUE, which was the only manifestation of long-term lung involvement due to SARS-CoV-2 pneumonia.
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Affiliation(s)
- Luana Nosetti
- Lombardy Regional Sudden Infant Death Syndrome Center, Division of Pediatrics, F. Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Massimo Agosti
- Department of Neonatology, Neonatal Intensive Care Unit, and Pediatrics, F. Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Massimo Franchini
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Azienda Socio Sanitaria Territoriale, Mantova, Italy
| | - Valentina Milan
- Division of Pediatrics, F. Del Ponte Hospital, Varese, Italy
| | - Giorgio Piacentini
- Department of Surgical Sciences, Dentistry, Gynecology, and Pediatrics, University of Verona, Verona, Italy
| | - Marco Zaffanello
- Department of Surgical Sciences, Dentistry, Gynecology, and Pediatrics, University of Verona, Verona, Italy
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21
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Legare JM, Smid CJ, Modaff P, Pauli RM. Achondroplasia is associated with increased occurrence of apparent life-threatening events. Acta Paediatr 2021; 110:1842-1846. [PMID: 33452838 DOI: 10.1111/apa.15760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/01/2021] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
AIM To assess the clinical picture underlying apparent life-threatening events (ALTEs) occurring in infants with achondroplasia and provide guidance for evaluation after an event. METHODS A population of 477 individuals with achondroplasia was retrospectively reviewed, and information regarding possible ALTEs was recorded in a REDCap database. RESULTS ALTEs occurred in the first year of life in 18 of 477 individuals (3.8%). Most (14/18, 78%) occurred in the first 6 months of life and presented as episodes of apnoea and/or seizures. Of affected infants, 8/18 (44%) had more than one episode. Many of the initial ALTEs arose while infants were in car seats (11/18, 61%). Assessment following ALTEs most often demonstrated either craniocervical junction concerns and/or seizures, with 12/18 (67%) patients undergoing cervicomedullary decompression and 5/18 (28%) starting on anti-epileptic medications after the event. CONCLUSION Although this study is limited in size and was retrospective, it shows that infants with achondroplasia appear to be at high risk for ALTEs. Evaluation after an event should include neuroimaging of the foramen magnum, inpatient hospital observation including respiratory monitoring and electroencephalography, and a car seat challenge.
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Affiliation(s)
- Janet M. Legare
- University of Wisconsin School of Medicine and Public Health Madison WI USA
| | - Cory J. Smid
- Children's Hospital of Wisconsin Medical College of Wisconsin Milwaukee WI USA
| | - Peggy Modaff
- University of Wisconsin School of Medicine and Public Health Madison WI USA
| | - Richard M. Pauli
- University of Wisconsin School of Medicine and Public Health Madison WI USA
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Is there a common denominator for Brief Resolved Unexplained Events, Sudden Infant Death Syndrome, and alleged Shaken Baby Syndrome? Med Hypotheses 2020; 144:109939. [DOI: 10.1016/j.mehy.2020.109939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 11/17/2022]
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Alhaboob AA. Clinical Characteristics and Outcomes of Patients Admitted with Brief Resolved Unexplained Events to a Tertiary Care Pediatric Intensive Care Unit. Cureus 2020; 12:e8664. [PMID: 32699664 PMCID: PMC7370642 DOI: 10.7759/cureus.8664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to determine outcomes of patients admitted to a tertiary care pediatric intensive care unit (PICU) with brief, resolved, unexplained event (BRUE), and to review the diagnostic and treatment options utilized for such patients. A retrospective data analysis was conducted for infants and children who were admitted to the PICU at a tertiary hospital with a diagnosis of BRUE over a period of three years (2015-2017). The study included 30 infants, 15 males, and 15 females. All patients survived to hospital discharge. The most frequent presenting symptoms and signs were apnea (73.3%), cyanosis (60.0%), and cough (20.0%). The most frequent reported affected systems were respiratory (33.3%), gastrointestinal (20%), and infection-related illness (20.0%). We conclude that the careful history taking, complete physical examination, and the appropriate workup for patients with BRUE play an integral role in optimum health service and utilization of critical care beds. Survival to hospital discharge with no serious in-hospital events warrants the adaptation of evidence-based medicine guidelines to stratify such patients based on the risk of recurrence or a serious underlying condition. Prospective multicenter studies are recommended to explore the effectiveness of such guidelines implementation on outcomes and diagnostic testing in such patients to optimize the utilization of the limited critical care beds.
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DeLaroche AM, Haddad R, Farooqi A, Sapién RE, Tieder JS. Outcome Prediction of Higher-Risk Brief Resolved Unexplained Events. Hosp Pediatr 2020; 10:303-310. [PMID: 32152008 DOI: 10.1542/hpeds.2019-0195] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Brief resolved unexplained events (BRUEs) are classified as higher risk on the basis of patient and event characteristics, but there is limited evidence to guide management decisions. The authors of this study aim to describe patients with a higher-risk BRUE, determine the yield of diagnostic evaluation, and explore predictors of clinical outcomes. METHODS A retrospective medical record review was conducted for patients ≤365 days of age who were evaluated in a tertiary-care pediatric emergency department with a discharge diagnostic code indicative of a BRUE. Demographic and clinical characteristics, including diagnostic evaluation, are reported. Univariate and multivariate analyses were used to test the association of risk factors with clinical outcomes (serious underlying diagnosis, recurrent events, and return hospitalization). RESULTS Of 3325 patients, 98 (3%) met BRUE criteria and 88 were classified as higher risk; 0.6% of laboratory and 1.5% of ancillary tests were diagnostic, with 4 patients having a serious underlying diagnosis. Nine patients had recurrent events during hospitalization, and 2 were readmitted for a recurrent BRUE after their index visit. Prematurity was the only characteristic significantly associated with an outcome, increasing the odds of a recurrent event (odds ratio = 9.4; P = .02). CONCLUSIONS The majority of patients with a BRUE are higher risk, but the yield of diagnostic evaluation is low. Published risk criteria do not appear to be associated with adverse clinical outcomes except for prematurity and recurrent events. Future multicentered prospective studies are needed to validate risk stratification and develop management guidance for the higher-risk BRUE population.
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Affiliation(s)
- Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Detroit, Michigan;
| | - Rita Haddad
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Detroit, Michigan
| | - Ahmad Farooqi
- Children's Research Center of Michigan and Wayne State University, Detroit, Michigan
| | - Robert E Sapién
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico; and
| | - Joel S Tieder
- Divisions of General Pediatrics and Hospital Medicine, Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
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